Secondary

Check here if you have secondary insuranceIf you do not have any additional insurance, please proceed to the Medical History tab.

Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:

Last, First MI

Relationship to Insured:

Spouse
Child
Other

Sex:

Male
Female

Address:

City: State: Zip:

Phone Number:

Birthday:

SSN:

Employer/School:

Tertiary

Check here if you have tertiary insuranceIf you do not have any additional insurance, please proceed to the Medical History tab.

Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:

Last, First MI

Relationship to Insured:

Spouse
Child
Other

Sex:

Male
Female

Address:

City: State: Zip:

Phone Number:

Birthday:

SSN:

Employer/School:

Medical History

Primary Care Physician

:

Ethnicity
Race
Flu Shot

Referring Doctor:

Primary Vision Correction

Type of CLs worn in past:

Interested In Contact Lenses?

Interested in Laser Vision Correction?

Patient Medical History

Systemic Medication

Allergies:

Family Ocular History:

Tobacco Use:

Alcohol Use:

Height:

ft
inches

Weight:

Review of Symptoms
Please check box if you have any of the following:

Fever, Weight Gain/Loss

Contact Lenses

Retinal Detachment

Eye Turn

Emphysema

Seasonal Allergies

Glaucoma

Flashes/Floaters

Sinus Problems

Skin Problem

Diabetes

Arthritis

Migraines

Cataracts

Blindness

Macular Degenration

Seizures

Anemia

Difficulty when driving

Lazy Eye

Asthma

Distorted Vision / Halos

High Cholesterol

Cancer

High Blood pressure

Thyroid

Refractive surgey

4+ hours of computer use

Diarrhea

Bleeding Problems

Kidney/Bladder problems

Constipation

Chronic Bronchitis

Submit Form

You are almost finished!

Dr. Uyeda's assistant will go over the following files with you in the office. Please read them over so you will be able to determine your options or be ready to ask questions when you come in for your appointment.